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A man huddles under a Portland overpass at 12a.m., today, shaking and convulsing in the frigid winter winds, and the invisible claws that rake over his mind. Rain pelts against the feeble walls of what was once a tent, filling the confines with muted noise like bubble wrap under a rolling pin. The kitchens will open later. Perhaps tomorrow he will find help. Perhaps tomorrow will be different.

A gaunt woman with wispy, frayed hair and wild eyes sprawls almost defiantly over two seats of a TriMet coach, eying another commuter exiting the train. “There she goes,” the gaunt woman sneers shortly after. “I had to do that to her. Her face was too happy.”
But she shared no interactions with the other commuters, and her remarks are for someone that no one else can see.

Sgt. Geddry and his partner pack their gear and paper cups of coffee into a police cruiser this morning in Vancouver, Washington. Their task for today is to retrieve and bring a man to the veteran’s hospital. The man, placed under a mental health hold (a judge-signed civil warrant mandating appearance at a hospital), is massive - a towering 6’4” 240lb former marine - and currently uncooperative.

Somewhere, a person exits a therapy office. Their fifth session. They had hoped that therapy would help, but there’s so much to be undone, so much time needed to do it, and only so much money to go around.
Perhaps tomorrow will be different.

By the end of “today” over 500,000 911 calls will be received. Approximately 10 percent of those calls - according to the most recent data available, The 2017 National 911 Progress Report, published by the U.S. Department of Transportation - will be mental health calls.

Despite what we may see, the majority of the calls will resolve peacefully. However, those that do not will, as they have for years now, bring one question to the forefront:

Why does this keep happening?

“It’s complicated” remains the most accurate, if least sexy, explanation. The answer is not as concise as "more training for members of law enforcement," or as simple as, "an ongoing need to improve the mental healthcare system."

What follows is not a series of accounts about the economics, politics and infrastructure that provided the U.S. with an increasingly dysfunctional mental healthcare system, though each do play a part. Instead, taken together these accounts provide a narrative about the impact of that disfunction on human beings. This is a chance to take a glimpse into the lives of the people who inhabit this world of mental illness, and empathize.

The economics and politics and infrastructure issues all point to an essential question: Will we, as members of society, make efforts to participate in the societal remedies we demand? 

The people and their complexities are what matter. It’s not about the symptoms represented by these stories. It’s about the disease. Because, while the symptoms are often the killer element, the disease is what needs to be remedied. The disease is America’s dysfunctional mental health system. The disease has long been fueled by public apathy.

And the disease kills people.

Sgt. Geddry and his partner exchanged glances, confirmed once more that the man was the only one in the building, and turned around back toward the patrol car to wait out the storm. Backing off to a respectful distance has become a standard response used by Vancouver officers encountering mentally and emotionally distressed persons, he says. It is an effective and significant step forward in crisis response -- one that may not have taken place mere years ago.

This seemingly simple strategy belies the magnitude of the issue many officers (and the people they respond to) have faced over the years.

More latitude in methods of responding is beginning to produce better results.

But, we are still left with our questions: How did this happen? How did police officers come to be the first responders to mental health crises? Why are these crises not handled by health care professionals?

These questions are important, but they are not the right question.

In a cruel sort of irony, the decline of America’s mental healthcare system can be traced back to a change in public policy that was grounded in the best of intentions;

Decades ago - nearly six of them, to be exact - the plight of the mentally ill in the nation’s mental asylums came to the center of public attention. Patients in these institutions spent days, weeks and months at monotonous tasks, waxing floors and vegetating in “dormitory rooms” between two or three featureless daily meals. It was a largely purgatorial affair that caught the attention of the press, and the ire of the public. In response, the National Mental Healthcare Act of 1963 aimed to shutter the traditional asylum in favor of community-based care.

For the purpose of providing a cultural reference point to associate with the time period, consider this: The video cassette was invented one year later. Today, of course, the VHS tape is obsolete three times over, which serves to illustrate how far back the crisis in the mental health system goes.

The shuttering of the asylums left the former patients in freefall.

The failure to follow through on the concept of community care stole away any sort of safety net, leaving the mentally ill to fend for themselves, physically and psychologically, on the streets.

Rapid social change left police departments creating new response procedures on the fly.

Officers were faced with the responsibility of managing a population that had previously been under the care of professional mental health providers with the better part of a decade’s worth of schooling. Moreover, these patients, who often react poorly to intense and prolonged stress, were suddenly thrust into those very circumstances. And to round out the trifecta of terrible, as if Life benevolently sought to remind its subjects that things can always be worse, these people lost any and all structure, shelter or medical order that had once dominated their lives, courtesy of the same act that endeavored to save them.

And this, the question of how this loss of services and structure affected, and continues to affect, the mentally ill, is the right question.

What makes mental illness so challenging is the extent of its volatility. As a general rule, and maybe with a hint of irony, many of us understand that mental illness is volatile. This awareness has been the driving force behind countless movements to improve police response. But the depth of the thing is easily lost on those who have not experienced such responses firsthand. To do so requires stepping into a mind whose workings are entirely alien.

Imagine, for a moment, what it would be like to be trapped in the confines of your own mind. To be trapped by your mind; to feel like a passenger in your own body -- a bystander to your own day; to see figures that do not exist, but appear more real than anyone you’ve ever known; for tireless voices to circle you and whisper your deepest, most raw insecurities and fears; for even the slightest task to become completely physically and emotionally draining; to feel your interests die, your ability to focus dance just out of reach; to feel isolated in the company of those closest to you.

Spiraling further out of control, your avenues for seeking help are sequestered behind financially crippling fiscal barriers and potential ostracism of friends, family and society.

And the people most commonly sent to help you have either never been prepared or are barred from doing so in any meaningful long-term way. It is difficult to put such an existential horror story to words with any sort of brevity, and even more so to imagine it empathetically. However, it is these stories that provide insight into the daily realities for many with mental illnesses.

This is where the issue of loss manifests the most, both today and 60 years ago. Loss of shelter - of a place to call home - is a devastating enough ordeal for even the most mentally sound of persons, even those having an established system of friends and family to fall back on. The asylum tenants of last century and many mentally ill today frequently do not have these safety nets, often being abandoned by family, and falling into unemployment or other similar circumstances. This loss of shelter would be ruinous enough on its own, without the added effects of having medical influence ripped away at the same time. Ask anyone who has tried to quit smoking cold-turkey, for example, and they will describe, with enthusiastic distaste, the special breed of misery that is breaking the body’s chemical dependencies. The same concept goes for a sudden “quitting” of medications for mental illness. The keystone difference being, in this case, the chemical dependency is due to the brain being made more functional by the substance (medication), rather than less (cigarettes).

Unchecked mental illness combined with the sudden chemical whiplash of medication withdrawals and compounded by the rigors of homelessness can often lead to inexplicable behavior to untrained eyes. These are the people, often with similar and recurring circumstances, that have largely nowhere left to turn, and law enforcement has been pushed to address the problems of how to respond to the resulting inevitable crises. At its core, many of the tragedies we see today are the result of one section of society - law enforcement - shouldering two enormously stressful and multifaceted duties - law enforcement and mental health first responder - and needing to do so with very little governmental or societal assistance.

Pete Perez, while now retired, possess over 20 years of law enforcement experience. While he has seen training dramatically improve the outcomes of the majority of crisis calls, police forces are still faced with two notable issues:

First, no amount of training can fully prepare someone outside the medical field to respond to a mental health crisis. 

Second, officers frequently have limited capacity to help the mentally ill in any long-term way.

Law enforcement’s capacity to respond does vary from state to state. For example, California, where Pete served his law enforcement career, employs a health and safety code - 5150 - that grants officers the ability to take a mentally ill person into custody if they meet certain criteria. The officer must determine whether the person can be said to be a danger to themselves - attempting suicide, self-harm, etc.

Alternatively, the officer(s)  must determine if the person is considered “gravely disabled,” or unable to take sufficient care of themselves, or a danger to other people due to their current mental state. If the person meets 5150 criteria, the officer can take them to a hospital or emergency room and place a hold on them for 72 hours. During that 72 hours the now-patient’s mental health is evaluated by appropriate hospital staff, who take over until the hold ends.

In Pete’s experience, the 5150 is one of the main tools law enforcement uses in mental health crisis response. However, laws may constrain an officer’s ability to intervene, he says.

Driving through Portland on his way home one afternoon, Pete (having retired at this point) spotted a man slouched against a curb. His head and face were covered in blood. Out of concern for the man’s condition, Pete pulled over and approached him. After several attempts to engage the man to ascertain his well-being, it appeared that he was not cognizant enough to respond. Unable to determine whether the problem stemmed from mental troubles, a physical altercation or being under the influence, Pete called 911 and explained the situation. However, the dispatcher explained that their station had already responded to the man’s situation, and that he was refusing treatment.

As it stood, there was nothing else they could legally do for him.

Experiences such as this are a source of frustration for many officers, Pete says. While it was unclear what issues the bleeding man was facing, he explains, there have been times in his career where the systems and protocols the police force ascribe to have not been the most appropriate or effective ones for the situation.

If someone has six warrants for public intoxication, for example, or a track record of being affected by mental illness, he later expanded, they would be better served by being taken to a recovery facility rather than to the station.

To further complicate things, the lack of access to mental healthcare can be even more damaging than inappropriate or inadequate police response. Were there an appropriate outlet for the ill after being taken into police custody, things could be more manageable for all involved. As it stands, police officers most often have to temporarily incarcerate the mentally ill, and from there they are released back onto the streets.

Michael David Crawford has fought with his Schizoaffective Disorder - an intermingling of bipolar disorder and schizophrenia - for decades. Outwardly, this is a fact very few people would be likely to pick up on. He looks to be like any middle-aged man you might see in line for coffee. The sole exception to this are his eyes. They wear the bags and weariness of someone who has lived through 100 years of hardship in just 54. Michael has written extensively on his journey, but has made special efforts to record the difficulties he faced in combating his illness, and the consequences confronted by the mentally ill because of their conditions.

I can’t claim all the credit, he says, but even since the beginning I’ve always known that I need help.

As is the case with many people with schizophrenia, his early symptoms manifested as auditory hallucinations, more colloquially known as hearing voices.

At the beginning of his experiences, he would hear some threatening voice calling his name. Pay phones he walked by would ring only to his own ears, and figures that did not exist threatened and stalked him throughout the day. Through a long and complicated process, he was committed to a mental hospital for treatment with $10,000 of health insurance coverage.

It was gone in less than 30 days, after which he could no longer afford the hospital’s services. That was in 1985.

His bipolar disorder has offered up its own slew of challenges.

Imagine Bipolar disorder as a coin.  There are two sides: Mania and Depression.

Mania could be considered to be the "better" or "kinder" side of the coin. You feel good. You feel good enough to take on the world. You can work faster, have more energy, and more focus to direct that energy.  It can be a confidence booster, but that confidence is misplaced. Because, most importantly, the brain can only handle being over-active for so long.

The effects of mania can vary from person to person. Some make numerous, impulsive and often exorbitant purchases, and others endure spells of unusually intense euphoria or irritability. His was dangerous, Michael explains, because of how it affected his perceptions of reality. Combined with his schizophrenic tendencies, Michael experienced periods of believing he was a secret service agent. The reason, he says, is quite literally because he knew a guy, who knew a guy who knew President Jimmy Carter. “There’s always a kernel of truth” to the delusions, which is part of what makes them so dangerous to the person with the illness. It is possible for an entire life to be thrown off-course because of a believable false perception.    

The other side of the coin, Depression, is exactly what it sounds like. It’s like the color bleeds out of life. Living becomes monochromatic. All the little things that make you "you" lose their meaning. Everything feels hollow. Laughing, moving, and making conversation are just actions made to maintain normalcy, losing their value and depth.  

Imagine mania as a period of constant ‘movement’ for the brain.  Nothing can keep working at 150 percent effort forever, and eventually that ‘movement’ exhausts it, dropping it abruptly and harshly into a depressive phase.

And the worst of the matter, he explains, is that the low-income mentally ill have absolutely nowhere to go for treatment, and few people to turn to for assistance.

This is not strictly limited to medical matters, either. If the right thing goes wrong, it can send a life off-course just as easily as delusions can.

“I have a bad attitude,” he jokes conspiratorially. "I blocked a bus stop once and waited for the police to show up. Once they did, I didn’t comply when they told me to move." One officer tased him. Michael told him “Horn works, try the wipers.” A more shocking experience for the officer than for Michael, but not without purpose.

“I wanted to go to jail so I could tell my story to a jury.”

While homeless, finding access to the medication he so desperately needed in order to function proved to be nearly impossible. As he attempted to find work again, his illnesses ran him down. He spent entire days in bed, his own body feeling unnaturally heavy.  Spiraling into depression, he attended a free clinic hosted by Oregon Health Sciences University in the hopes of being prescribed antidepressants.

His request was denied.

Because the practitioner was unsure whether or not the medication would induce mania, the clinic declined to supply any prescription. While the importance of careful diagnosis and prescription should not be minimized, Michael raised a question that should at least be considered:

    “...Is it really better for someone to lose their job, become homeless or even commit suicide because you don’t want them to get arrested when they’re manic?”

Today, Michael lives in an apartment under a permanent assisted housing agreement, which, he explains, has been found to be significantly less expensive for the government than rotating the mentally ill between jails and the streets.

Even assuming that an addict, for example, continues “using” during their time in the housing, they are still committed to jails less frequently, alleviating needs for additional staffing at those facilities. Since moving into his new apartment, Michael has gotten off of food stamps, needed only two trips to an emergency room due to his mental health and has maintained a good credit standing.

In addition to working a job again, the specifics of which he requested remain unmentioned, Michael continues to write accounts of his experiences with mental illness.

He was inspired to do so not because of his own experiences, but by the Heaven’s Gate cult suicide in 1997. For background, the Heaven’s Gate Cult was led by a man called Marshall Applewhite, and he and his followers lived in a single house in San Diego.

Isolation, Michael says, is the most dangerous thing to someone with a mental illness. Once someone is on their own, with no one to spot warning signs or help them course-correct, the symptoms of mental illness, often ones that affect the way reality is perceived, will ravage a mind relentlessly.

In the case of Heaven’s Gate, Michael explains, the people living in the house became isolated as a group rather than individuals, which can be just as dangerous for the human brain, even one that does not deal with mental illness. The members of the cult committed to the suicide so enthusiastically that they prepared funeral shrouds and purchased Nike Decade sneakers “so as to be properly dressed for the occasion.”

    ”The whole world recoiled in horror at those Nike Sneakers. I recoiled in horror because I understood why they did that...What [isolation can do to] anyone.”

While the right question to ask may have been discovered, devising and implementing a plan to appropriately address the issues the question exposes is still a process in the conceptual phase.

Improving crisis response within police departments has clear merit. It would be a disservice to imply otherwise. However, despite the efforts of a great many officers and citizens, the evidence still depicts a nation continuing to search for a system that addresses the needs of the mentally ill.

But the issue runs deeper than just the mechanics of the system itself. In examining these accounts, we find that what law enforcement and the mentally ill are facing is a functionally infinite loop of interactions.

The ill have few feasible avenues for preventative care or recovery, eventually spiraling into rampant, untreated mental illness, homelessness or both.

Police officers, driven by both a sense of duty and public pressure, respond to the inevitable crises that come with unchecked illnesses. However, even assuming the benefits of effective crisis response training, officers are strictly limited in what they can actually provide for someone in crisis. All too often the ill are cycled into and out of jails. Even when those jails offer some manner of mental healthcare, the ill rotate through so quickly that most “treatment” either has no time to take root, or renews the cycle of loss when they return to the streets.

From illness, to the streets, to the jails and then back to the streets, and on and on the wheel turns.

Because no system devised so far has broken the cycle, broadly speaking, officers and the ill see each other again, and again, and again, dozens of times or more.

And perhaps they coexist peacefully. As Mr. Perez said, more often than not the relationships formed between these people who see each other nearly every day are respectful, and even friendly.

Eventually, though, as it has so many times before, something will go horribly wrong. A misreading of body language, a mental break from reality, an unwittingly poor choice of words, or just simply being in the wrong place at the wrong time on someone’s wrong day.

The laws of statistics do not favor those caught in an infinite loop. An endless cycle of interactions is an endless number of opportunities for disaster, like walking across a frozen pond. One step, two steps, stable surface; three steps, and the ground unexpectedly gives way to icy unforgiving blackness.

Police officers performing the role of first responder is not the solution, nor should we expect it to be. Perhaps at one time it was a solution; a bandaid to cover a freshly opened wound. However, recognizing and taking action against a symptom usually assumes future action to remedy the disease, and failing to do so has placed additional burdens on the victims of a dysfunctional system.

Whether consciously or otherwise, all of us play a role in a hundred stories, some large, some small, some with happy endings and some that end in tragedy. Each day provides equal opportunity to try to make the world a better place by, to put forward heartfelt cliches, “being the change” we wish to see.

To participate in the societal repairs we demand.

To gift some small kindness - a smile, a hello, a sandwich, a listening ear - to someone who needs it.

To choose to create a safer place for hundreds of thousands of men, women and children  by following through on the spirit of our thoughts and prayers.

To understand the thoughts - the minds - of the mentally ill, and the due process constraining their first responders.

Societal change has historically occurred on a timescale that would make glaciers seem expedient, and mental illness requires consistent care over long periods of time. The two have coiled together in a feedback loop now for nearly six decades.

It is possible that the answer to the right question may not start in policy, institutions or standardized training.

“I’d like to mention one last thing.” Michael said. “The single biggest thing that can be done to help the mentally ill, the addicts and people who are homeless for any reason, often women or even children escaping domestic violence: Just treat them with simple, human respect. That’s it. By shaking the hand...that has been deemed unworthy of being shaken, you may very well have saved a life.”

~ ~ ~

Thank you to the people who contributed to making this project a reality.